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Lifestyle Medicine > Section 9: Tobacco and Alcohol Use > Flashcards

Section 9: Tobacco and Alcohol Use Flashcards

1
Q

Tobacco

A
  • Single largest preventable cause of morbidity and mortality
  • Smokers lose -10 years of life
  • Smokers suffer more health problems and disability
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2
Q

Health effects of modern cigarettes

A
  • Inc. risk of lung adenocarcinoma, most common type of lung cancer
  • kills 1 one of every two people who use them
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3
Q

Smoking leads to or causes:

A
  • Diabetes
  • Rheumatoid arthritis
  • Impaired immune system/immune function because some chemicals damage the immune system
  • Reduced quality of life
  • Problems with reproduction in men and women
  • Slower wound healing
  • Tuberculosis disease
  • Ectopic pregnancy, preterm delivery stillbirth, sudden infant death syndrome
  • Cleft lip and cleft palate (if smoking while child is in utero)
  • Erectyle dysfunction
  • Age-related macular degeneration
  • Failure rate of treatment for all cancers
  • Risk of bone fractures
  • Muscle aches and pains
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4
Q

Key drug in addiction to cycle of tobacco products

A

Nicotine

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5
Q

Smoking cessation benefits

A
  • Immediate quitting: cut heart attack risk by 50% vs non quitting
  • 1 year: heart disease risk is 50% of a non-smoker
  • 2-5 years: risk of stroke approximately same of non-smoker
  • 10 years: risk of lung cancer reduced by 50%
  • Quitting at 30 years: gains 10 years life expectancy
  • Quitting at 60 years gains 3 years of life expectancy
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6
Q

Tobacco Cessation

A
  • Most people who quit smoking do so without evidence based tx. But cold turkey is the least effective in long term.
  • 50% will resume within 14 days
  • 75% will resume within 30 days
  • Only 5% will be able to quit without assistance
  • There are more former smokers than current smokers today
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7
Q

Lung Cancer Screening

A

Screen those with following criteria:
- Greater or equal to 30 pack year smoking history
- Current smoker or quit within past 15 years
- Between age of 55-80 years of age

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8
Q

10 Key recommendations from USPHS Guidelines

A
  1. Clinicians need recognize that tobacco dependence is a chronic disease and should be treated and appropriately followed up
  2. Should consistently assess and document tobacco use
  3. Txs are effective across broad range of population
  4. Brief tobacco dependence tx is effective
  5. Individual, group, and telephone counseling is effective (more intense intervention, more effective). Person to person of more than 4 sessions appears to be especially effective.
  6. Numerous effective meds exist
  7. Combination of counseling and meds is more effective thatn either alone
  8. Telephone “quitline” counseling is effective.
  9. If user is not ready to quit, use motivational interviewing skills to increase future quit attempts.
  10. Tobacco dependence tx are clinically effective and very cost effective vs other tx for other disorders
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9
Q

Pharmacotherapy Guidelines

A

Use effective meds except:
- Tx is contrindicated
- Special populations where there is insufficient evidence (pregnant women, smokeless tobacco users, light smokers, adolescent)

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10
Q

First Line Medications

A
  • Patch alone: 45% tobacco free at 8 weeks
  • Lozenge alone: 40% tobacco free at 8 weeks
  • Nicotine replacement inhaler or nasal spray (prescription only)

Varenicline: the most effective monotherapy (51% tobacco free at end of 12 week program, 35% tobacco free at 6 months
(it’s a nicotinic receptor partial agonist, meaning, binds to the same receptors as nicotine. Hence prevents withdrawal but stops nicotine highs.

Bupropion: 40% tobacco free at 8 weeks (inhibits reuptake of norepinephrine and dopamine

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11
Q

Treatment combinations

A

Combination of Varenicline and bupropion is the MOST EFFECTIVE treatment
- Combination of bupropion patch and lozange
- combination of bupropion and lozenge

Combination of varenc

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12
Q

Treatment combinations

A

Combination of Varenicline and bupropion is the MOST EFFECTIVE treatment
- Combination of bupropion patch and lozange
- combination of bupropion and lozenge

Combination of varenicline, bupropion and nicotne replacement therapies only preliminary data is available

Tripple therapy is recommended:
- Bupropion, patch and nicotine replacement therapy

Two second line meds (off label)
- clinidine and nortriptyline (if first line meds have not worked or contraindicated)

  • Light smokers (<10 cigarettes per day) show NO SIGNIFICANT BENEFIT from nicotine replacement therapy

Bupropion will not prevent weight gain

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13
Q

Treatment in special populations

A

If with Mental illness:
- May need higher doses, longer duration of tx, combination of meds

BIPOLAR:
- DO NOT USE bupropion
- Patch is RECOMMENDED TREATMENT

SCHIZOPHRENIA
- Patch is RECOMMENDED

CARDIOVASCULAR DISEASE
- No association between nicotine patch and acute cardiovascular events
- Use CAUTION in px with cardiovascular disease when using nicotine replacement therapy

PREGNANT SMOKERS:
- Counseling is best
- Bupropion and varencicline: FDA category C for use during pregnancy
- Prescription nicotine replacement therapy: Category D with potential risk of birth defects

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14
Q

Duration of treatment

A
  • Long term nicotine replacement has no known health risk
  • Bupropion is approved for up to 6 months
  • Varenicline can be used up to 6 months
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15
Q

e-cigarettes

A
  • Not FDA regulated
  • “no nicotine” have been found to contain nicotine
  • Contains less harmful chemicals compared to tobacco. but still contains heavy metal
  • Associated with EVALI (E-cigarette or Vaping product use Associated Lung Injury)
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16
Q

5As for Tobacco Cessation

A

ASK: Identify tobacco use and document px
ADVISE: advise px
ASSES: is px ready to quit?
ASSIST: Provide counsel for those who are ready
ARRANGE: schedule follow up

Alternative:
ASK, ADVISE, REFER

  • Use motivational interviewing to increase future quit attempts
17
Q

Alcohol Consumption

A

Moderate:
- 1 drink per day for women
- 2 drinks per day for men

Binge drinking:
- Drinking enough that blood alcohol level increases to 0.08 mg/L
- 5 drinks in 2 hours for men
- 4 drinks in 2 hours for women

Heavy Alcohol Use:
- Binge drinking on more than 5 days in the past month
- More than 4 drinks on any day for men
- More than 3 drinks on any day for women

At risk drinking:
- Exceeds levels above for any day or week
- Binge drinking at least once a month
- Drinking that increases risk of future problems

18
Q

Alcohol Use Disorder

A
  • More appropriate term because it’s a continuous spectrum
  • “alcoholism” and “alcoholic” no longer used. Stigmatizing and imprecise.
19
Q

Most common symptoms of AUD

A
  • Significant distress or impairment
  • Impaired control over use
  • Cravings and preoccupations
  • Persistent but unsuccessful desire to quit or cut down
  • Use despite adverse consequences such as hangover, nausea, heartburn, depression, and other health problems
    -10% of people with AUD develop serious adverse consequences, including job, legal, and role failure problems
  • The most severe 10% are over represented in rehabs, jails, and hospitals
20
Q

DSM 5 for AUD

A
  1. Drank too much/long than planned
  2. Tried quitting, but couldn’t
  3. Spent lot of time drinking, took long to recover from hangover
  4. Wanted drink badly, couldn’t think of anything else
  5. Drinking interfered with family, school, or work
  6. Continued drinking despite causing problem with family/work
  7. Stopped hobbies in order to drink
  8. Caused you to do harmful things (unsafe sex, walking in dangerous street, etc)
  9. Continued drinking despite knowing it makes you feel depressed/ black out
  10. Had to drink more in order to get effect
  11. Withdrawal symptoms
21
Q

AUD Diagnostic criteria

A

0-1: criteria met; no AUD
2-3: mild (similar to DSM-4 alcohol abuse)
4-5: moderate (similar to DSM-4 alcohol dependence)
6+: severe

22
Q

Clinical process for screening

A
  • Annual prevention
  • High risk groups: young people, high risk regions, trauma/STD, family history, pregnant or planning to be pregnant, heavy smokers, clinical suspicion
  • Oral survey: ask px how many times drink:
    1. Number of drinking days per week
    2. Number of drinks per day
    3. Advice should be gibve to reduce or stop if not in moderation drinkling
  • Alcohol Use Disorder Identification Test (AUDIT) (available online)
  • It is the recommended screening test
    5-10: at risk
    11-15: more at risk
    16+: high probability of moderate or severe AUD
23
Q

AUDIT-C

A

Rated 0 (low number of occurrences) to 4 (daily, high number of occurrences)

  1. How often do you have drinks containing alcohol?
  2. How many drinks containing alcohol do you have on a typical day when you are drinking?
  3. How often do you have six or more drinks on one occasion?

If score more than 5, may indicate hazardous or harmful drinking.
(Men more than 4, women more than 3)

24
Q

Alcohol Misuse Interventions AT RISK DRINKERS WITH MILD AUD

A

Signs and Symptoms:
- exceed 5 or more drinks per drinking occasion at least monthly
- One to three symptoms of AUD
- Risk increases with intensity and frequency of drinking
- Primary risks: AUD development, liver disease, and marital problems

What to do:
- brief advice to reduce
- Naltrexone 25-50mg by mouth, as needed at time of drinking occasion
- Follow up booster sessions to improve effectiveness

Resource: “Rethinking Drinking”

25
Q

Alcohol Misuse Interventions MILD TO MODERATE AUD

A

Symptoms:
- Going over limits
- Desire to cut down
- Use despite adverse consequences
- Tolerance
- Usually occurs as an isolated episode, possibly lasting 3-4 years, then resolves
- Similar to functional depression

Management:
- Primary care setting, not an addiction clinic
- Behavioral health
- Anti relapse medication (as effective as addiction counseling, similar effect size as SSRI antidepressants)

26
Q

Alcohol Misuse Interventions SEVERE RECURRENT AUD

A

Risk factors:
- Family history
- Early childhood neglect
- Behavior problems in childhood
- Early onset
- Chronic or recurrent course
- Other substance abuse and psychiatric disorder

Treatment:
- Counseling
- Anti relapse medication
- Lifestyle intervention may be difficult due to the level of impairment
- REFER to an addiction specialist especially if there is life impairment and px is not compliant or initial intervention not effective

27
Q

Lab Test to Track

A

GGT (Gamma-glutamyl transferase)
- Helpful if initially elevated

28
Q

Anti Relapse Medications

A

First Line:
- Naltrexone 50mg by mouth daily or twice daily
- Acomprosate - modulates glutamate neutrotransmission

Second line meds:
- Disulfiram 250mg by mouth daily (inhibits aldehyde dehydrogenase)
- High rates of non compliance, not more effective than placebo

  • Gabapentin 300-600mg by mouth 2 or 3 times daily
  • Well tolerated, but there’s concern for possible abuse potential
  • Topiramate 100-150mg by mouth twice a day
  • Off label
29
Q

US Standard Drink Size

A

12 oz - 1 beer
5 oz - table wine
1.5 oz - shot

30
Q

Excessive alcohol ass. with

A

10% cancer, 20% intentional injuries. 7% deaths (road crash, cancer, suicide)

Lifestyle Medicine (11 decks)

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